Inquest finds multiple failings by Cambian Churchill Hospital in death of 25-year-old patient

An inquest into the death of 25-year-old James O’Brien, also known as Jimmy, has concluded that there were multiple failures by Cambian Churchill Hospital

3 March 2017

An inquest into the death of 25-year-old James O’Brien, also known as Jimmy, has concluded that there were multiple failures by Cambian Churchill Hospital in their response to James’ collapse during the night of 8th to 9th December 2015.

The inquest jury found that that staff failed to trigger the alarm, failed to start resuscitation, provided inadequate information to the ambulance service, carried out inadequate resuscitation and failed to appropriately use the defibrillator. The jury concluded that earlier intervention might have made a difference to James’ survival.

The jury went on to find that Cambian had failed to ensure staff were adequately trained and knew how to respond to an emergency. They also found Cambian failed to provide adequate inductions to staff. HM Coroner will be issuing a Prevention of Future Deaths report to Cambian in due course.

The inquest into James’ death was heard by a jury between 27th February and 3rd March 2017 at Southwark Coroner’s Court, London.

James died on 9 December 2015 while sectioned under the Mental Health Act in the Cambian Churchill Hospital in Lambeth south London, run by the Cambian Group. His cause of death was sudden cardiac death in schizophrenia.

The inquest heard that James has suffered a catatonic episode and vomited on the evening of 8th December and had later collapsed.

The staff member who found James collapsed carried out no basic checks. He alerted the nurse in charge of the ward, who also failed to carry out basic checks and walked away to call an ambulance without attempting to provide any immediate life support. The nurse in charge was an agency nurse who was unable to provide the full address of the hospital or basic information about James.

No staff members carried out any resuscitation attempts for around four minutes and then evidence was heard that no rescue breathes were given and chest compressions by hospital staff, led by a nurse, were ineffective and not in accordance with national guidelines. No one raised the hospital alarm when James was found.

An independent expert commented that although staff obtained the hospital defibrillator, the pads were applied incorrectly and the voice commands weren't followed.

Paramedics arrived and despite their efforts, James later died at St Thomas Hospital.

Despite a critical investigation report commissioned by Cambian into James' death, their lawyers at the inquest stated there was no admission from Cambian in relation to the matters the report identified.

James' mother also raised concerns about how she was treated by the Hospital Director, Gemma Body, in the aftermath of her son's death. A further investigation was commissioned which concluded that there was a significant failure in communication to James’ mother at the time of his death. The investigation made 24 recommendations to the hospital including the revision of its complaints procedures, revision of policies regarding sudden deaths and emergency admission to hospital and communication with families.

James was described by his family as a “bright and gifted” boy who was popular with his peers and an active sportsman. However, they began to notice a change in his personality after he began smoking cannabis at around the age of 18.

Over the next few years his smoking of cannabis escalated and his mental health declined. His family sought help for him and he was admitted to the Priory in 2011 where he was first diagnosed with cannabis induced psychosis.

In 2012 he was sectioned at Chase Farm Hospital where he was formally diagnosed with schizophrenia. He spent time in and out of the hospital and was sectioned a number of times. He was admitted to Cambian Churchill Hospital in March 2014 and detained under section 3 MHA.

He often complained to his family about suffering with heart palpitations but despite raising this with the clinical staff the family felt like nothing was done to help him with this or find the cause.

James had been diagnosed with Disorganised Schizophrenia with periodic catatonic features, substance abuse and substance induced periodic catatonia.

James’ mother Chrissy Kountourou, of Oakwood north London, said on behalf of the family:

“Cambian let Jimmy down and they let my family down. If Cambian had done their job properly my son might still be alive today. I welcome the jury’s findings which support what my family and I have said all along.

“I feel that Cambian have treated me appallingly since my son’s death and to have it now recognised that they failed Jimmy before his death is of some comfort.

“I hope Cambian management will reflect fully on the jury’s findings and ensure changes are made that prevent another family having to endure what we have.”

“Jimmy, a patient under Cambian’s care, and his family have been wholly let down by Cambian as reflected by the jury’s finding of a catalogue of errors involving multiple staff.

“Jimmy was deprived of potentially life saving treatment and as Cambian staff failed to carry out immediate checks on him when he was found, there is no evidence as to whether Jimmy was alive at that point.

“Patients detained due to mental ill-health deserve better care and organisations such as Cambian must be willing to openly acknowledge their failings, rather than forcing a bereaved family to have to seek these through the inquest process.”

Ms Kountourou was represented at the inquest by Merry Varney, of Leigh Day, and Kate Beattie of Doughty Street chambers.